Cape Breton Regional Municipality
PROCUREMENT SECTION, FINANCIAL SERVICES 320 ESPLANADE, SUITE 100 SYDNEY,NS B1P 7B9 PHONE: 902-563-5146 FAX: 902-539-9964 EMAIL: dmmurphy@cbrm.ns.ca
CHECK LIST
PRIOR TO SUBMISSION PLEASE CHECK THAT YOU HAVE THESE
DOCUMENTS SUBMITTED WITH ALL REQUEST FOR TENDERS
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SCHEDULE “A” – MUNICIPAL BY-LAW COMPLIANCE CERTIFICATE
□
APPENDIX “A” – CONSULTANT, CONTRACTOR SUPPLIER HEALTH
AND SAFETY QUESTIONNAIRE
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TRIPLICATE (3) COPIES OF TENDER SUBMISSION SEALED AND
PROPERLY LABELED WITH CORRECT NUMBER
P17.2014
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LETTER OF GOOD STANDING FROM WORKERS COMPENSATION
(WCB)
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PROOF OF CURRENT AND VALID WORK PLACE SAFETY
CERTIFICATE OF RECOGNITION (COR) FROM AN AUTHORIZED
INSTITUTION
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GENERAL INSURANCE
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BID SECURITY – CERTIFIED CHEQUE PAYABLE TO CAPE BRETON
REGIONAL MUNICIPALITY OR BID BOND ON CCDC FORM 220
FOR TEN (10)% PERCENT OF THE TENDERED SUM
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RECEIVED ADDENDA NO. _____ TO NO._____ INCLUSIVE
FAILURE TO COMPLY WITH ABOVE MAY RESULT IN DISQUALIFICATION
OF YOUR BID.
Cape Breton Regional Municipality
PROCUREMENT SECTION, FINANCIAL SERVICES 320 ESPLANADE, SUITE 100 SYDNEY,NS B1P 7B9 PHONE: 902-563-5146 FAX: 902-539-9964 EMAIL: dmmurphy@cbrm.ns.ca
INSTRUCTIONS TO BIDDERS
Sealed Tenders will be received by the undersigned up to 2 P.M., THURSDAY, SEPTEMBER 18, 2014 for the following:
REQUEST FOR PROPOSAL P17.2014
ARCHITECTURAL/ENGINEERING SERVICES – ROOF REPLACEMENT – PUBLIC WORKS CENTRAL
Forms and Specifications: must be obtained from the Procurement Section, Financial Services, Suite 104, 320 Esplanade, Sydney, N. S. B1P 7B9. Phone (902) 563-5015 or E-Mail purchase@cbrm.ns.ca .
Addenda: vendors must monitor the Nova Scotia Government Tenders Website for any addenda that may be issued. CBRM staff no longer maintains plan takers lists, and no longer have knowledge of who has downloaded opportunities.
Sealed Bids: must be sealed and designated P17.2014 and return TRIPLICATE (3) COPIES to the Procurement Section, Financial Services Suite 104, 320 Esplanade, Sydney, N. S. B1P 7B9.
NOTE: FAXED / ELECTRONIC submissions are not acceptable and will not be considered
Opening: will be opened at a public tender opening on THURSDAY, SEPTEMBER 18, 2014 at 2 PM. in the first floor boardroom of the Civic Centre, 320 Esplanade, Sydney, N. S. The determining clock used for authentication of date and time is the computer clock used by the Manager of Financial Services.
Tenders requiring bid deposit: If tender requires a non-refundable bid deposit only those companies who have compiled with this request will be considered for acceptance.
Tender Contents
(Section Applies to: Construction Contracts, Services & Sale of Municipal Property ONLY!)
Bid Security: Each tender must be accompanied by a certified cheque payable to the Cape Breton Regional Municipality or a Bid Bond on CCDC Form 220 for ten (10) percent of the tendered sum. Any withdrawal of the successful tender shall constitute forfeiture of the bid deposit.
Performance Security: A Performance Bond in the amount of fifty (50) percent contract price and Labour and Material Payment Bond in the amount of fifty (50) percent of the contract price will be required upon notification of award and before the signing date of the contract or issue of the Purchase Order.
Alternate Securities Acceptable: As an alternate to the Security Deposit and the Consent of Surety requirements stated herein, Contractors may submit a ten (10) percent bid security certified cheque, and subsequently upon notification of award, an additional ten (10) percent contract security certified cheque, in lieu of contract stated bonding.
Accompanying Documents: All bids must include the following documents:
- The signed Schedule “A” Municipal By-Law Compliance form attached to the tender documents. If this document is not signed and returned it will deem the contractor non-responsive and the contract will be in breach.
Cape Breton Regional Municipality
PROCUREMENT SECTION, FINANCIAL SERVICES 320 ESPLANADE, SUITE 100 SYDNEY,NS B1P 7B9 PHONE: 902-563-5146 FAX: 902-539-9964 EMAIL: dmmurphy@cbrm.ns.ca
- Proof of current and valid Workplace Safety Certificate of Recognition(COR) from an authorized institution(East Coast Mobile Medical, HSE Integrated Limited, Nova Scotia Construction Safety Association (NSCSA), Nova Scotia Trucking Safety Association, Occupational Health and Educational; Services 2002 Inc, Safety Services Nova Scotia or equivalent)
- Completed/signed Appendix “A” Consultant, Contractor, Supplier Health & Safety Questionnaire. - General liability insurance.
Prior to Contract Award – In accordance with section nine (9) of the CBRM Procurement Policy, the successful tenderer shall be required to provide an approved Commercial Property Zoning Confirmation, issued by CBRM’s Development Officer, prior to award of contract.
Following completion of the tendered work, letters of clearance from both organizations, dated no earlier than the final day worked on the project, must be submitted with the final invoice for the project. This will form a condition of the tender in addition to any other conditions within the contract documents and specifications.
POLICY:
• The Agreement on Internal Trade (AIT), Atlantic Procurement Agreement (APA) and The Cape Breton Regional Municipality Procurement Policy are the governing documents used for all tenders. Copies of these documents are available from the Financial Services Department, Procurement Section, Suite 104, 320 Esplanade Sydney, N.S. or by phoning (902) 563-5015
• Where identical goods and/or services are available, from a Cape Breton Regional Supplier, and a supplier from outside the regional area, the following shall apply:
o Regional suppliers will be allowed a 5% pricing preference, over suppliers outside the region
when the total bid price before taxes is less than $25,000 on Goods, $50,000 Services and $100,000 on Construction.
o Regional suppliers qualify for the 5% price preference if they are a commercial taxpayer in the
Cape Breton Regional Municipality.
• Successful bidder will be required to follow CBRM protocol as designated by Purchasing Department for delivery and invoicing.
• Payment: Any supplier having an account due to the Cape Breton Regional Municipality, which is in arrears, will have such arrears deducted from payments being made to the supplier.
The Cape Breton Regional Municipality reserves the right to reject any or all tenders or to accept any tender or part thereof considered to be in its best interest.
Donna Murphy
Donna Murphy, Buyer Financial Services
Cape Breton Regional Municipality
PROCUREMENT SECTION, FINANCIAL SERVICES 320 ESPLANADE, SUITE 100 SYDNEY,NS B1P 7B9 PHONE: 902-563-5146 FAX: 902-539-9964 EMAIL: dmmurphy@cbrm.ns.ca
SCHEDULE “A”
MUNICIPAL BY-LAW COMPLIANCE CERTIFICATE
This document forms part of and is incorporated in to the Tender. Bidders convicted of violations of any Cape Breton Regional Municipal By-Laws or found in contravention of the Dangerous and Unsightly Provision of the
Municipal Government Act, S.N.S. 1998, c. 18 shall be precluded from bidding on the tender. Successful bidders who subsequently are found guilty of violation of any Cape Breton Regional Municipal By-Laws or are found to have contravened the Dangerous and Unsightly Provision of the Municipal Government Act S.N.S. 1998, c. 18 shall have the tenders revoked and shall be precluded from bidding on subsequent tenders for a period of thirty-six months.
__________________ (hereinafter referred to as “The Bidder”) does hereby certify that the Bidder has not been found guilty of violation of any Cape Breton Regional Municipal By-Laws and has not been found to have contravened the Dangerous and Unsightly Provision of the Municipal Government Act S.N.S. 1998, c. 18 and furthermore hereby agrees to comply with all Cape Breton Regional Municipal By-Laws and the Dangerous and Unsightly provision of the Municipal Government Act, S.N.S. 1998, c. 18. The Bidder understands and agrees that any finding of guilt or contravention of any Cape Breton Regional Municipal By-Laws and provisions will result in the Tender being revoked and the Bidder being precluded from bidding on any subsequent Tender for a period of thirty-six months.
________________________ ________________________
Witness Bidder
CBRM INTERNAL USE ONLY
Approved by: ____________________________
Title:
____________________________
CAPE BRETON REGIONAL MUNICIPALITY
OCCUPATIONAL HEALTH & SAFETY POLICY AND PROCEDURE MANUAL
SUBJECT: Contractor Safety Management Section: 12 Issued: May 1998 Revision: March 2010
Effective: June 1, 2010 Supersedes: July 2004
12.01 POLICY STATEMENT
The Cape Breton Regional Municipality (CBRM) is subject to the Nova Scotia Occupational Health and Safety Act (the Act) when contracting for the services of external Contractors, Consultants and suppliers. This policy has been developed to confirm CBRM’s commitment to maintain a safe and healthy work environment and to prevent workplace accidents and illness.
12.02 DEFINITIONS
“CBRM Employee” mean persons who are employed directly with CBRM.
“CBRM Representative” means a person appointed by the director, manager or supervisor of the business unit to oversee the contractor or supplier.
“Consultant” means a person or company who has been hired by CBRM to oversee, manage or complete a project in conjunction with contractor(s).
“Contractor” means a person who contracts for work to be performed at the premises of CBRM or contracts for work on a CBRM project and includes a sub-contractor.
“Employee” means a person who is employed or contracted to do work by a contractor.
“Employer” means a person other than CBRM who employs one or more employees or contacts for services of one or more employees.
“Supplier” means a person who manufactures, supplies, sells, leases, or distributes or installs any tool, equipment, machine or device or any biological, chemical or physical agent to be used by an Employer or Employee.
12.03 POLICY OBJECTIVES
The objective of this policy is to establish and clarify the duties and procedures of each party in carrying out their responsibilities under the Act. It will help clarify the procedures necessary to reduce incidents or accidents, damage to equipment or property and ensure the health and safety of all CBRM Employees and those of the Contractor.
12.04 APPLICATION General
This policy is meant to compliment the Act and in the event of any conflict between this policy and the Act, the Act
will prevail.
CBRM
This policy applies to all members of management and employees of the CBRM that are involved with or is requesting the contracting of work on behalf of CBRM, or that work with or in the vicinity of external Consultants, Contractors or Suppliers, or are involved with the procurement of external Consultants, Contractors or Suppliers.
Consultants, Contractors and Suppliers
This policy applies to anyone that undertakes work or work on a project for CBRM by way of contract. All contractors utilized by CBRM and their employees will comply with the Act and applicable regulations, as well as any applicable CBRM policies or practices. This policy also applies to anyone who acts as a Supplier or Consultant in relation to CBRM directly or any of its external contractors.
12.05 ENFORCEMENT & ADMINISTRATION CBRM
CBRM to the extent of its ability and authority will take all reasonable steps to monitor all Contractors and Suppliers for compliance with the Act, regulations and CBRM safe work practices and procedures. In the event of a noncompliance, CBRM will take necessary steps to ensure compliance is achieved.
It will be the responsibility of each director, manager and supervisor of the business unit contracting for services, to ensure that this policy and all other applicable policies and procedures are being adhered to. The director, manager, or supervisor of the business unit shall appoint a CBRM Representative to oversee the Contract work and/or the Supplier. The name of the Representative and contact information shall be provided to CBRM procurement and the Contractor or Supplier as the case may be.
Inspections will be conducted and documented by the CBRM Representative for the purposes of ensuring that work is being conducted in a safe and healthy manner and to ensure compliance with the Act. In the event of non – compliance with the Act the CBRM Representatives shall ensure appropriate corrective action is taken as required. At any time during contracted work, a CBRM Representative may conduct a site inspection and take or order whatever corrective action is deemed appropriate at the time.
When safety violations are observed by the CBRM Representative, the Occupational Health and Safety Manager or any CBRM employee, the appropriate director, manager, or supervisor will ensure corrective action is immediately taken and a Contractor Safety Violation Report (Appendix “B”) will be completed and sent to the Manager of Financial Services as well as the Occupational Health and Safety Manager.
All Contractors, Consultants and Suppliers at the time of Tendering are required to agree to the CBRM’s mandatory minimum Health and Safety requirements as stated in the Tender document, as well as complete a “ Contractor Health and Safety Questionnaire” ( Appendix “A”)
12.06 POLICY DIRECTIVES Policy Review
This policy shall be reviewed as required to ensure it remains current, meets the requirements of CBRM work practices and compliance with applicable legislation. Review of this policy will be done in consultation with CBRM Joint Occupational Health and Safety Committees and Representatives.
Posting Requirements
This policy is to be readily accessible to all Employees, Contractors, Consultants and Suppliers, and shall be posted on the CBRM Website, and distributed to all Departments for insertion in their safety manuals.
Each Department will be responsible and accountable for developing, implementing, supervising and the training of employees in this policy.
12.07 RESPONSIBILITIES
The general duties and responsibilities of CBRM, CBRM employees, contractors, consultants and suppliers and their employees and others are set out in the Act. Generally, the provisions require each individual ensure to the extent of their ability to do so, the health, safety and welfare of workers.
CBRM
CBRM is an owner and employer under the Act and like all employers and owners will continue to be responsible for compliance with the Act. As owner of the property CBRM will make every precaution reasonable in the circumstance to maintain their land or premises used as workplace in a manner that will ensure the health and safety of persons at or near that workplace, and in a manner that is in compliance with the Act and regulations. CBRM will provide to any Contractor, Consultant or person that may be performing a workplace activity, any information that is known by CBRM or information that CBRM could reasonably be expected to know, that would be necessary to identify, eliminate, or control hazards relating to the health and safety of persons at the workplace.
Duties the Department Director, Managers and Supervisors
Workplace health and safety has been assigned by CBRM to each Department Director. Each Department Director, Manager and Supervisor will familiarize him or herself with the provisions of the Act.
It is the responsibility of the Department Director, Managers and Supervisors to provide information, instruction, training, supervision and facilities necessary for the health and safety of CBRM employees while working with or in the vicinity of external contractors.
Ensure CBRM employees, are familiar with any health or safety hazards they may be exposed to while working with or in the vicinity of external contractors and suppliers and to implement appropriate corrective action to prevent such exposure.
Ensure compliance with the Act and applicable regulations and this policy.
Appoint a CBRM Representative who is trained and competent to deal with external contractors and suppliers. Ensure inspections are conducted and documented for any contracted work their business unit is involved with to ensure that both CBRM Employees and external Contractors, Consultants and Suppliers and their employees are working in a safe manner and utilizing the appropriate protective devices, measures and procedures required. Ensure Chief Administrative Officer is informed of any significant contractor activity, any work related death, or any decision of the business unit related to health and safety that may have negative implications;
Ensure the investigation of all near misses, personal injuries and property damage involving workers or external Contractors under their control, and to report these findings to the Health and Safety Committees and the Occupational Health and Safety Manager.
Evaluate health and safety performance of all contracted work and provide feedback to the Financial Services Department.
CBRM Employees and those of External Contractors
Every employee shall work in compliance with the Act and applicable regulations; guidelines, and codes of practice and CBRM Occupational Health and Safety Manual.
Adhere to all safety programs, policies, safe work procedures and safety directives relating to health and safety performance;
Take all reasonable precautions in the circumstance to protect their health and safety and the health and safety of others at or near the workplace;
Report all safety hazards or unsafe conditions using the following protocol, immediate supervisor, manager, safety committee, safety representative or the Department of Labour and Workforce Development, if the situation is not appropriately resolved;
Report all personal injuries, property/equipment damage, or near miss incidents to your immediate supervisor. In the event of a personal injury, obtain first aid or other medical assistance immediately;
Use all personal protective equipment as required by regulation, CBRM policy, or at the direction of a supervisor; Use only machinery, tools, or equipment for which you have been properly trained in and authorized to use; Co-operate with the Joint Occupational Health and Safety Committees, safety representative, the employer, external contractors or any person performing a duty under the Occupational Health and Safety Act and regulations;
Consultant or Contractor
Every Consultant or Contractor shall take every precaution that is reasonable in the circumstances to ensure the health and safety of persons at or near the workplace or project;
Comply with, and ensure that every sub-contractor, employee, self-employed person and employer performing work at the workplace complies with the Act and applicable regulations and CBRM safe work practices, policies, procedures and safety program;
Must co-ordinate their work manner that will ensure the health and safety of other workers, CBRM employees or people at the workplace;
Take appropriate corrective or disciplinary action against any sub-contractor or employee in contravention of health and safety legislation, which may include but not limited to the suspending of work until appropriate corrective action is implemented;
Ensuring that any directives or orders issued by the Department of Labour and Workforce Development are appropriately addressed in a timely manner and that the CBRM Representative is immediately informed of any such directives or orders.
Communicate all information necessary for the health and safety of persons at the work place;
Contractors shall assign a trained and competent person to oversee health and safety while working on CBRM property and shall provide the name and contact information of such person. The assigned person shall coordinate, cooperate and communicate with the CBRM Representative for the purposes of ensuring the health and safety of the workplace.
Contractors will be responsible for providing and maintaining certified first aid responders and applicable first aid supplies on site. Contractors are responsible for the development of emergency procedures, including the transportation of an injured employee to the hospital if required.
Contractors will be required to conduct hazard assessments and implement appropriate control measures, maintain their work site in a clean and orderly manner and to ensure appropriate supervision and trained, competent staff are on site.
Where required by legislation, contractors will be required to establish and maintain the appropriate safety committees or representatives.
Contractors are responsible for reporting all serious injuries, accidents or fatalities to CBRM representatives immediately.
Supplier/Manufacturer
Every supplier shall take every precaution that is reasonable in the circumstances to ensure that any device, equipment, machine, material or item supplied is in a safe condition, provided with all required safety devices, manufacturers specifications and instructions pertaining to the safe use of the product;
Ensure that any device, equipment, machine, material or item supplied is in compliance with the Act and applicable regulations;
Communicate any instructions regarding the safe use and or safety equipment necessary for the safe use of any device, equipment, machine, material or item supplied;
Maintain the supplied product in a safe condition, if it falls under their realm of responsibility;
Ensure that any biological, chemical or physical agent supplied is properly labeled and provided with the appropriate MSDS sheets required by regulations;
Occupational Health and Safety Manager
A resource that will provide assistance, advice and make recommendations to directors, managers, supervisors, joint occupational health and safety committees, external contractors, suppliers and employees in relation to health and safety matters;
Occupational Health and Safety Manager will perform the role of advisor/resource and will not assume the responsibility of directors, managers and supervisors for the implementation and enforcement of health and safety policies, safe work procedures/practices and the safety program;
Will utilize the authority assigned to them by senior management, for stopping or shutting down any CBRM workplace or part of a workplace, projects or part of a project, or taking any equipment out of service, that poses or may pose an imminent danger to employees, external contractors, or people at or near a workplace, or that is in violation of the Occupational Health and Safety Act or applicable regulations;
Conduct as required, safety inspections and audits in the workplace, on projects or any site where an external contractor may be utilized by CBRM and recommend control measures as required;
12.08 POLICY MONITORING
The Director in each Department involved with Consultants, Contractors, or Suppliers will ensure that monitoring the implementation of this policy takes place and that there is reporting on the performance and effectiveness of health and safety for contractors and contracted work.
CBRM
CBRM will actively monitor and audit compliance with this Contractor Safety Management Policy and legislated standards. Departments may be audited and evaluated on their occupational health and safety performance and policy/program compliance at any given time, with or without previous notification.
12.09 CONSULTANT/CONTRACTOR /SUPPLIER SAFETY PERFORMANCE
If a Consultant’s, Contractor’s, or Supplier’s safety performance is not in accordance with Nova Scotia Occupational Health and Safety Legislation Regulations or CBRM's Occupational Health and Safety Manual, where the CBRM representative has knowledge of such violations, the following will apply:
1) The Contractor shall be given notification listing safety deficiencies using Contractor Safety Violation Report in Appendix B.
2) The Contractor shall acknowledge notification, indicating corrective action taken, including action to prevent recurrence.
3) Should the Contractor refuse to take appropriate corrective action, the Occupational Health and Safety Manager shall be contacted incase the Nova Scotia Department of Labour and Workforce Development may have to be contacted immediately.
4) Continued unsatisfactory safety performance will have a negative effect on the Contractor’s ability to obtain future CBRM contract work.
12.10 REFERENCES
Occupational Health and Safety Act, Chapter 7 of the Acts of 1996, amended 2000, c. 28, ss. 86, 87; 2004, c. 6, s. 24; 2007, c. 14. s. 7
Reference Guide to the Occupational Health and Safety Act, Department of Environment and Labour, printed on January 2009.
APPENDICES
“A” – Contractor Health and Safety Questionnaire
APPENDIX “A”
CAPE BRETON REGIONAL MUNICIPALITY
CONSULTANT, CONTRACTOR, SUPPLIER HEALTH & SAFETY QUESTIONNAIRE
Consultants, Contractors or Suppliers wishing to submit Proposal\Tender to the Cape Breton Regional Municipality must complete this questionnaire and submit it to CBRM Finance Department with their bid information.
GENERAL INFORMATION:
Company Name: ______________________________________________________ Company Address: ______________________________________________________ Telephone Number: ______________________________________________________
INSURANCE/WORKERS’ COMPENSATION COVERAGE:
Is your company covered by general liability insurance, automotive insurance, umbrella policies, etc., that would cover the cost of damages to, and incidents involving third parties?
Is your company in good standing with the Workers’ Compensation Board for the Province of Nova Scotia?
If no, please explain _______________________________________________________________
SAFETY PERFORMANCE:
Does your company have any non-compliance or outstanding issues with the Nova Scotia Labour and Workforce Development, such as stop work orders, pending charges/prosecutions, or recent (within the last year) convictions or fines?
If yes, please attach a note explaining the details, including current status or resolution.
SAFETY PROGRAM:
Does your company have a written health and safety policy signed by management?
Does your company have written safety policies, procedures and safe work practices applicable to the scope of work to be performed, including clearly defined safety responsibility for managers, supervisors and workers?
How do you communicate your safety policies and procedures?
________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ How often do managers/ executive officers visit the worksite? _____________________________
* Yes * No * Yes * No
* Yes * No
* Yes * No * Yes * No
Please explain how you conduct on-site inspections, including how often they are conducted, what they cover and who conducts them?
________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Does your company have a risk assessment procedure?
Does your company have a procedure in place for investigating incidents, accidents and near misses?
Please attach a list and contact information of all supervisors you will be using on site, as well as any safety coordinator or persons responsible for job site safety.
Do you provide on the job training to all employees?
Please indicate how you inform your workers, other workers or persons at or near the workplace of any workplace hazards to which they may be exposed.
________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Do you have a disciplinary policy in place for anyone committing health and safety violations?
Please Describe:
________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Do you have a Joint Occupational Health and Safety Committee or Representative?
Do you have a preventative maintenance program for tools and machinery?
Do you have a health and safety policy in place for incorporating sub-contractors into the workplace?
Please provide any other information relating to other programs or activities that you believe demonstrate your company conducts their projects safely and in accordance with all health and safety requirements.
NOTE:
PLEASE BE ADVISED THAT DURING THE PROPOSAL\TENDER ING PROCESS OR AT ANYTIME DURING THE CONTRACTED WORK, CBRM MAY REQUEST COPIES OF POLICIES, PROCEDURES, RECORDS OR DOCUMENTATION OF PROOF FOR ANY QUESTIONS ANSWERED ON THIS QUESTIONNAIRE.
DO YOU AGREE TO PROVIDE THIS INFORMATION IF REQUESTED?
* Yes * No * Yes * No * Yes * No * Yes * No * Yes * No * Yes * No * Yes * No *YES *NO _______________________________________ ____________________________________ Signature Date Position/ Title
APPENDIX “B”
CAPE BRETON REGIONAL MUNICIPALITY
CONSULTANT, CONTRACTOR, SUPPLIER SAFETY VOILATION REPORT
To: __________________________________________________________________________ From Management Representative: _______________________________________________ Date: ________________________________________________________________________ Safety Violation: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Date of Observation: ___________________________________________________________ Location: _____________________________________________________________________ Observed By: _________________________________________________________________ Action Taken: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________
